Provider Demographics
NPI:1992923155
Name:POWERS, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:POWERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2280 S WOODWORTH LOOP
Mailing Address - Street 2:
Mailing Address - City:PALMER
Mailing Address - State:AK
Mailing Address - Zip Code:99645-7412
Mailing Address - Country:US
Mailing Address - Phone:907-746-4646
Mailing Address - Fax:907-746-4653
Practice Address - Street 1:2280 S WOODWORTH LOOP
Practice Address - Street 2:
Practice Address - City:PALMER
Practice Address - State:AK
Practice Address - Zip Code:99645-7412
Practice Address - Country:US
Practice Address - Phone:907-746-4646
Practice Address - Fax:907-746-4653
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK70282085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology